Situation assessment of rehabilitation in Georgia

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Situation assessment of rehabilitation in Georgia

February 2020

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Situation assessment of rehabilitation in Georgia

February 2020

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with different Government ministries and State agencies, development partners, United Nations agencies, nongovernmental organizations, disabled people’s organizations and rehabilitation users. It adopted a realist synthesis approach, responsive to the unique social, cultural, economic and political circumstances in the country. The content of this document serves to provide a snapshot in time – not an in-depth analysis of the entire rehabilitation sector. The assessment focuses on rehabilitation policy and governance, service provision and human resource with the aim of improving access to high-quality rehabilitation services in Georgia.

Keywords

REHABILITATION IN GEORGIA: SITUATIONAL ANALYSIS.

1. Rehabilitation. 2. Rehabilitation policy. 3. Rehabilitation services. 4. Rehabilitation – human resources.

5. Rehabilitation 2030. 6. Person with disabilities – rehabilitation and assistive products. 7. Universal health coverage. I. World Health Organization.

Document number: WHO/EURO:2021-2393-42148-58068.

© World Health Organization 2021

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Acknowledgements

This report was made possible through the combined efforts of the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (MoIDPLHSA), the World Health Organization Regional Office for Europe and the extensive network of stakeholders involved in rehabilitation in Georgia.

This assessment would have been inconceivable without the leadership, vision and technical concept development provided by the First Deputy Minister of MoIDPLHSA, Dr Tamar Gabunia, and the commitment of the MoIDPLHSA Policy Department, specifically the representatives of the Social Unit and Health Unit.

Many thanks to the United States Agency for International Development (USAID), Georgia and Washington (DC), for its continued commitment to rehabilitation and the resources needed to accomplish this task. This situational assessment has been made possible by the generous support of the American people through USAID. The contents do not necessarily reflect the views of USAID or the United States Government.

Contributors

Authors

Satish Mishra, WHO Regional Office for Europe; Sue Eitel, WHO Regional Office for Europe; Mzia Jokhidze, MoIDPLHSA; Nino Jinjolava, MoIDPLHSA; Giorgi Kurtsikashvili, WHO Country Office in Georgia

Editors

Satish Mishra, WHO Regional Office for Europe; Silviu Domente, WHO Representative and Head of WHO Country Office; Tamar Gabunia, First Deputy Minister of MoIDPLHSA

Peer contributors (individuals and organizations)

Health, social, financial, human resources and emergency units and departments at MoIDPLHSA; L. Sakvarelidze National Centre for Disease Control and Public Health; Adjara Ministry of Health and Social Affairs; Social Rehabilitation Centre for Persons Having Limited Ability; Georgian Association of Physiotherapists; USAID project management team; Physical Rehabilitation Programme Georgia, Emory University/Partners for International Development; MAC Georgia; GCECI; Ilia State University; Ivane Javakhishvili State University (TSU); Tbilisi State Medical University; Foundation Aures; Ken Walker Clinic, Tbilisi State Medical University Rehabilitation Department;

Social Rehabilitation Centre for Persons with Disabilities; First Step in Georgia; Studio ADC; Neurodevelopment Centre; Coalition for Independent Living; D. Tatishvili National Centre CIU NPO Georgia; Georgian Occupational Therapists’ Association; Georgian Deaf Union; Wolfram Syndrome Georgia; Woman, Child and Society; Georgia Care Platform; Chairman of the Blind Union; Aversi Rehabilitation Centre; Polyclinic #14 - Disability Determination Commission; Neuro-Developmental Centre; Georgian Foundation for Prosthetic and Orthopaedic Rehabilitation;

Chakvi Neurorehabilitation Centre; Batumi Shota Rustaveli State University; 1 Polyclinic Batumi; Caritas Tbilisi;

Abastumani Pulmonary Hospital; The National Hero Of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre; United Nations Children's Fund (UNICEF); Maya Mateshvili, local consultant.

Our gratitude goes to all individuals and rehabilitation users who generously shared their knowledge and experiences related to rehabilitation in Georgia. These contributions are essential to this report.

Peer reviewers

Kirsten (Kiki) Lentz, USAID; Manfred Huber, WHO Regional Office for Europe

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Abbreviations

ACTOR Action on Rehabilitation

AP assistive products

AT assistive technology

CBR community-based rehabilitation CIL Coalition for Independent Living ECI early childhood intervention

ESC&UAC Emergency Situations Coordination and Urgent Assistance Centre FRAME Framework for Rehabilitation Monitoring and Evaluation GAPTAR Georgian Association of Physical Therapy and Rehabilitation GEFPOR Georgian Foundation for Prosthetic Orthopaedic Rehabilitation GEL Georgian lari (currency)

Geostat National Statistics Office of Georgia GE-OTA Georgian Occupational Therapy Association GPTA Georgian Physical Therapy Association GRASP Guidance for Rehabilitation Strategic Planning GSLA Georgian Speech and Language Association HMIS Health Management Information System ICF International Classification on Functioning ICRC International Committee of the Red Cross IDP internally displaced person(s)

ISPO International Society for Prosthetics and Orthotics ISU Ilia State University

LDSC Latter-day Saint Charities LEPL legal entity of public law

MAC Georgia McLain Association for Children Georgia MICS Multiple Indicator Cluster Survey

MoD Ministry of Defence

MoES Ministry of Education, Science, Culture and Sport

MoIDPLHSA Ministry of Labour, Health and Social Affairs (shortened version of MoIDPOTLHSA)

MoIDPOTLHSA Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (also:

MoIDPLHSA)

NCDC National Centres for Disease Control and Public Health NCEQE National Centre for Educational Quality Enhancement

NDC Neurodevelopment Centre

NGO nongovernmental organization NQF National Qualifications Framework

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OOP out-of-pocket

OT occupational therapy/therapist P&O prosthetics and orthotics PT physical therapy/therapist RMM Rehabilitation Maturity Model SDG Sustainable Development Goals

SFTV Agency for State Care and Assistance for the (Statutory) Victims of Human Trafficking SLT speech and language therapy/therapist

SRAMA State Regulation Agency for Medical Activities

SSA Social Services Agency

STARS Systematic Assessment of Rehabilitation Situation SWOT strengths, weaknesses, opportunities and threats TRIC Template for Rehabilitation Information Collection TSMU Tbilisi State Medical University

TSU (Ivane Javakhishvili) Tbilisi State University UHCP Universal Health Care Programme

UNCRPD United Nations Convention on the Rights of Persons with Disabilities UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development WCPT World Confederation for Physical Therapy

WHO World Health Organization

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Executive summary

The rehabilitation sector in Georgia is evolving, and many examples of good practice are emerging.

That said, rehabilitation in Georgia is firmly rooted in child-focused social programmes and disability, and post-Soviet era treatment techniques and terminology continue to be used.

WHO states that rehabilitation is “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (1). In Georgia, the 2014 census shows that 2.69% of the population have a disability and that fully 35% have functional limitations (2).

The leadership of the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs (MoIDPLHSA) recognizes that rehabilitation is part of health care and a health strategy for the entire population, including people with disability.

The Ministry’s request to the World Health Organization (WHO) for technical assistance to assess the rehabilitation situation and work with it to develop a national strategic plan for rehabilitation is evidence of its commitment to developing the rehabilitation sector within the health system.

This assessment utilizes standard tools developed by WHO and is structured around the WHO building blocks for health system strengthening (leadership and governance, financing, health workforce, service delivery, medicines and technology, and health information systems).

MoIDPLHSA representatives, with technical support from WHO, led the in-country data collection for the rehabilitation situation assessment in Georgia from 10 to 28 February 2020. The assessment comprised over 40 semistructured interviews, focus group discussions and site visits to five locations: Tbilisi, Batumi, Akhaltsikhe, Abastumani and Tserovani (Mtskheta municipality). Over 100 stakeholders contributed to the process.

Preliminary findings from the assessment were discussed on 28 February in Tbilisi.

Although rehabilitation includes psychology and mental health, this assessment does not provide detailed information on mental health, as there is a separate State Programme for Mental Health (1995), managed by MoIDPLHSA, and a mental health strategy is being developed with support from the French Government.¹

Key findings

Rehabilitation is not new to Georgia, and there are many positive elements to be acknowledged.

Rehabilitation governance: MoIDPLHSA provides guidance on some assistive products and policy leadership for children with disability. There are focal points for rehabilitation within MoIDPLHSA and a commitment to strengthening rehabilitation in the country.

Rehabilitation financing: MoIDPLHSA, through the Social Services Agency (SSA), provides over US$ 4 million annually for rehabilitation and assistive products. The Autonomous Republic of Adjara (Adjara) provides over US$ 1 million annually for medical and social rehabilitation; in addition, it provides over US$ 200 000 annually for adult rehabilitation services.

1 Source: discussion with MoIDPLHSA First Deputy Minister, 10 February 2020.

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Rehabilitation human resources and infrastructure: specialization in rehabilitation is available for medical doctors in Georgia (through residency/postgraduate training); the profession is regulated and a licence to practise is required (the Certificate of Independent Medical Practice). In addition, there are accredited training programmes (at bachelor level and some at master’s level) for physical, occupational and speech therapy.

Rehabilitation information: the 2014 census collects information on disability and functioning. Health facilities send data annually to the National Centre for Disease Control and Public Health (NCDC).

Rehabilitation service accessibility and quality: early childhood development programmes are present in Georgia and there is an extensive network of rehabilitation services for children with disability.

One significant hurdle facing rehabilitation in Georgia is that it is inextricably linked with disability.

Some additional challenges and potential implications are outlined below.

Governance

1. Rehabilitation is not integrated into existing health policies: until rehabilitation is recognized as a fundamental part of the health-care continuum, it will continue to be viewed as purely a disability service.

2. There is no national strategy on rehabilitation: rehabilitation activities will be fragmented unless they are guided by one overarching document that includes all relevant departments, ministries and stakeholders.

3. Rehabilitation focal points exist, but collaboration is ad hoc rather than systematic: the lack of systematic coordination may stand in the way of a streamlined approach to developing the rehabilitation sector.

4. There is limited awareness of rehabilitation beyond its application to disability: a lack of clarity about the concepts of disability and rehabilitation may contribute to misunderstanding or limit the effective integration of rehabilitation into health systems.

5. There is only partial governance for, and availability of, assistive technology: underdeveloped programme structures, policy frameworks, procurement processes and guidance on the provision of assistive products may impede the development of this aspect of rehabilitation.

Financing

1. Rehabilitation services are not included in the Universal Health-Care Programme (UHCP): opportunities for effective and timely interventions to maintain or restore functioning will be limited until rehabilitation is recognized as an essential part of health care and incorporated into the UHCP.

2. The current voucher system does not consider treatment outcomes and may not cover individual needs or costs of treatment: the generic nature of vouchers (predetermined time frame, treatment course, funding) and lack of attention to outcomes may result in investment that is inefficient and/or ineffective.

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Human resources

1. There is inadequate regulation of the rehabilitation workforce: the lack of licensing and competencies (except for rehabilitation doctors), continuing education requirements or standards creates an inconsistent work environment (varying capacities and skill levels), which may undermine the integrity of the rehabilitation professions.

2. There is no national education programme, training plan or professional recognition for prosthetists and orthotists, i.e. prosthetics and orthotics (P&O) technicians: the lack of professional recognition and absence of a standard education programme or plan for prosthetists and orthotists creates an imbalance with other rehabilitation professions.

3. The rehabilitation sector has a plethora of professional associations and terminologies: multiple professional associations serving the same function, together with inconsistent application and understanding of rehabilitation terminologies, impedes the cohesive development of the sector.

Information

1. Information on population functioning in Georgia is not well publicized: noting that 28–35% of the population has limitations in functioning makes a stronger case for rehabilitation than quoting the figure of 2.69% people with disability.

2. There is a lack of consistent and consolidated information related to rehabilitation. The lack of uniform and centralized information on rehabilitation workforce, services and utilization creates challenges in identifying and reporting reliable baseline information.

Rehabilitation services

1. Rehabilitation for adults with health conditions is grossly underdeveloped in Georgia: neglecting this segment of the population reduces participation and potential economic contribution to society.

2. Timely rehabilitation interventions and inpatient rehabilitative care are extremely limited: rehabilitation requires immediate and intensive application to restore neural pathways and prevent secondary conditions.

3. Limited number and type of assistive products available in Georgia: appropriate assistive technology (products and provision) are key to creating opportunities for optimal functioning.

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Key recommendations

To address some of the challenges that Georgia faces related to rehabilitation, the following recommendations are submitted for consideration.

Governance

1. Consolidate rehabilitation leadership and coordination.

• It is recommended that the Government of Georgia:

1.1 establish a rehabilitation working group to develop and implement a national rehabilitation strategy and serve as a channel for ongoing communication in the sector;

1.2 develop a national strategy on rehabilitation that involves and includes all relevant ministries, departments and stakeholders.

2. Include rehabilitation in any newly developed, revised or updated health policy documents

• It is recommended that MoIDPLHSA:

2.1. incorporate rehabilitation into the National Health Strategy 2021–2026;

2.2. engage members of the rehabilitation working group to advise on language in health policy documents to ensure that rehabilitation is appropriately represented.

3. Raise awareness of rehabilitation

• It is recommended that MoIDPLHSA and relevant stakeholders:

3.1. design informational materials highlighting rehabilitation and functional gains, particularly aimed at health-care and social services staff;

3.2. share guidance on distinctions between, and intersectionality of, rehabilitation and disability.

4. Strengthen frameworks related to procurement and provision of assistive products

4.1. solicit support from WHO to assess the assistive technology situation in Georgia and include it in a national rehabilitation strategy.

Financing

5. Improve resource allocation for rehabilitation services across all levels of health care

5.1. introduce rehabilitation procedures into UHCP;

5.2. amend existing voucher system to link payments with evidence on treatment outcomes;

5.3. determine/update the optimal cost of the service package defined by the voucher.

Human resources

6. Resolve identified challenges related to the rehabilitation workforce

• It is recommended that MoIDPLHSA, together with the Ministry of Education, Science, Culture and Sport and other relevant stakeholders:

6.1. address the lack of training and professional recognition for prosthetists and orthotists;

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6.2. develop competencies, regulations and licensing requirements for staff working in physical (PT), occupational (OT) and speech and language (SLT) therapy and prosthetics and orthotics (P&O) staff;

6.3. upgrade clinical pre-service training ensure greater consistency between programmes and sites;

6.4. revise the continuing education requirements for all health staff;

6.5. consolidate professional associations and terminologies related to rehabilitation.

Information

7. Emphasize that the purpose of rehabilitation is to optimize functioning

• It is recommended that MoIDPLHSA, together with relevant stakeholders:

7.1. Repackage available information on functioning to highlight the demand for rehabilitation.

8. Support health facilities in collecting, consolidating and sharing rehabilitation-related information

• 8.1. incorporate information on rehabilitation workforce and service availability in the health facility reporting form submitted annually to NCDC;

• 8.2. train health staff in existing patient procedure codes regarding rehabilitation and nursing care.

Rehabilitation service

9. Reinforce efforts to ensure that adults with health conditions receive the rehabilitation they need

9.1. continue engaging with the working group dedicated to adult rehabilitation in Georgia.

10. Promote timely rehabilitation interventions across the continuum of health care

• It is recommended that MoIDPLHSA, together with relevant stakeholders:

10.1. replicate examples of good practice where rehabilitation is applied in acute care settings;

10.2. support inpatient rehabilitation to maintain or improve function;

10.3. encourage expansion of rehabilitation services at community level.

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1. Background

and methodology

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1.1 International, regional and national developments in rehabilitation

In February 2017, WHO launched the Rehabilitation 2030 initiative with a call for action (3) that identifies 10 areas for united and concerted action to reduce unmet needs for rehabilitation and strengthen the role of rehabilitation in health. (For an overview of rehabilitation strategies and interventions, see Annex 1.) WHO also released the Rehabilitation in health systems guidelines (4), which provide basic recommendations for strengthening rehabilitation in the health sector and integrating it more effectively across health programmes.

This body of work further supported the development of the Rehabilitation in health systems guide for action, released in 2019 (5). A central tenet of the WHO guidance is that rehabilitation is a health service for the whole population: it should be made available at all levels of the health system, and ministries of health should provide strong leadership to strengthen the health system to deliver rehabilitation and develop strategic rehabilitation plans. Information on the Guide for action and rehabilitation in relation to the WHO health system building blocks can be found in Annex 2.

The WHO Regional Office for Europe has initiated a four-year programme (2018–2022) to increase access to rehabilitation services and assistive products in the Region, and has identified Eastern Europe, central Asia and the Caucasus as a geopolitical priority – an area which includes Georgia.

Within Georgia, rehabilitation policies are strongly associated with disability policies. Georgia ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2013. Article 26 of the Convention refers to habilitation and rehabilitation. In 2017, Georgia drew up a draft law on the rights of persons with disability (not yet approved). The annual State Programme for Social Rehabilitation and Childcare is a key guidance document detailing benefits and subprogrammes for persons with disability.

1.2 Methodology

This assessment uses a newly developed method and reporting template, launched in 2018 by WHO, called the Systematic Assessment of Rehabilitation Situation (STARS). STARS is not an academic evaluation of rehabilitation, nor is it intended as a detailed analysis. It is a snapshot in time to review rehabilitation status, identify strengths and gaps and lay the foundations for a national strategic plan for rehabilitation.

The STARS process in Georgia occurred in two stages:

Stage 1: Completion and consolidation of a standard questionnaire (January 2020) Stage 2: Three-week in-country data collection and preliminary read-out (February 2020).

1.2.1 Stage 1 (completion and consolidation of a standard questionnaire)

In January 2020, MoIDPLHSA received the WHO Template for Rehabilitation Information Collection (TRIC). This questionnaire comprises eight sections with over 100 questions (six sections focused on the health systems strengthening building blocks plus additional sections on infrastructure and emergency preparedness). The focal points within the MoIDPLHSA Policy Department completed the questionnaire in Georgian and sent their responses to the WHO Country Office in Georgia. The TRIC responses were translated into English and sent to the consultant at the end of January.

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BAckGROUNd ANd METHOdOLOGy

1.2.2 Stage 2 (in-country data collection and preliminary read-out)

In-country data collection took place from 10 to 28 February 2020. (For an orientation map of Georgia, see Annex 3.) The assessment team comprised Mr Satish Mishra (WHO Regional Office for Europe), Mr Giorgi Kurtsikashvili (WHO Country Office, Georgia), Ms Nino Jinjolava and Dr Mzia Jokhidze (MoIDPLHSA Policy Department) and Ms Susan Eitel (international consultant). For the assessment team’s schedule during the visit, see Annex 4.

In the first week, the team focused on data collection in relation to the health system building blocks and a facilitated discussion on strengths, weaknesses, opportunities and threats (SWOT) related to rehabilitation in Georgia (for the team’s preliminary findings, see Annex 5). Additionally, the team conducted key informant interviews and site visits to health and rehabilitation services in five locations: Tbilisi, Abastumani (near Akhaltsikhe), Akhaltsikhe itself, Batumi and Tserovani (Mtskheta municipality). See Annex 6 for participant information.

The Rehabilitation Maturity Model (RMM) is another standard tool used during the STARS process. It includes 50 components across seven domains. Each component has illustrative descriptors that indicate the level of maturity of rehabilitation in the health system. The RMM provides an overview of the performance of various rehabilitation components. This overview enables comparison across components and domains that can then assist in the identification of priorities and recommendations for strategic planning. The international consultant took data from the TRIC and in-country data collection, and aligned this information with the 50 components.

This was used to help visualize the preliminary assessment findings presented on 28 February – see Annex 5.

A detailed breakdown of individual components of the RMM is provided in Section 11 below.

1.2.3 Limitations

The minor limitation identified during the assessment phase is the lack of a formal working group or committee to support the completion of the TRIC questionnaire, the SWOT analysis and feedback on preliminary findings.

This limitation was overcome by the extensive investment of time and effort by the rehabilitation focal points within the MoIDPLHSA Policy Department and highly committed stakeholders in the sector.

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2. Introduction

to rehabilitation

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WHO describes rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (3) (Fig. 1).

The term “health condition” refers to a disease (acute or chronic), disorder, injury or trauma. A health condition may also refer to other circumstances, such as pregnancy, ageing, stress, congenital anomaly or genetic predisposition.

Rehabilitation interventions are targeted actions to build muscle strength and improve balance, cognitive ability or communication skills. This skill-building can assist people in performing basic daily activities, such as moving around, self-care, eating and socializing.

Fig. 1. Aims of rehabilitation interventions

Source: Western Pacific Regional framework on rehabilitation. Manila: World Health Organization Regional Office for the Western Pacific; 2019 (https://iris.wpro.who.int/handle/10665.1/14344, accessed 10 May 2021). Licence: CC BY-NC-SA 3.0 IGO.

Rehabilitation also removes or reduces barriers in society through modifications in people’s personal environments, such as home, school or work, so that they can move around safely and efficiently.

In many countries, rehabilitation is closely associated with disability and is sometimes considered a disability service. However, rehabilitation is a health strategy for the entire population, including people with disability.

Rehabilitation is for all people, forming part of the continuum of health care and part of health systems.

Rehabilitation is important at all levels of the health system (tertiary, secondary, primary and community). For additional information on rehabilitation, see Annex 1.

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3. Health trends and

rehabilitation needs

in Georgia

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3.1 Georgia country context

The Georgia country context is complex, with different information sources describing the country in slightly different terms. For the purposes of this report, Georgia is deemed to consist of Tbilisi (the capital city), 10 regions (including Adjara) and two occupied territories – the Autonomous Republic of Abkhazia and the Tskhinvali/

South Ossetia region (see map in Annex 3).

According to the 2014 population census, Georgia’s population is 3 713 804, of whom 100 113 (2.69%) are identified as persons with disability. The census covered 82% (57 000 square kilometres) of the total area of the country. It could not be conducted in the occupied territories: the Autonomous Republic of Abkhazia and South Ossetia (total area 13 000 square kilometres) (6). According to the Statistical Yearbook of Georgia 2019, the population is 3 723 500 (not including the occupied territories) (7).

As at December 2018, Georgia has 293 000 internally displaced persons as a result of conflict and violence (8).

There is significant outmigration of the working-age population. An estimated 0.75 million Georgians (16.6% of the population) have emigrated; the primary destination country is the Russian Federation, followed by Ukraine and Greece (9).

A total of 83.4 % of the population of Georgia are Orthodox Christians, 10.7% are Muslims and 2.9% belong to the Armenian Apostolic Church.

Georgia is a developing country and ranks 70th in the Human Development Index.

3.2 Health context, trends and rehabilitation needs in Georgia

The health context or health trends can serve as proxy indicators of the demand for rehabilitation services. In Georgia, health trends or contextual factors include the rise of noncommunicable diseases, an ageing population and the number of persons with disability or difficulties in functioning.

3.2.1 The rise of noncommunicable diseases in Georgia

The main types of noncommunicable disease are cardiovascular diseases (e.g. heart attacks or stroke), cancers, chronic respiratory diseases and diabetes (10). In Georgia, noncommunicable diseases are estimated to account for 93% of all deaths (Fig. 2) (11).

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HEALTH TRENdS ANd REHABILITATION NEEdS IN GEORGIA

Fig. 2. Estimated mortality in Georgia

NCD: noncommunicable disease. Source: (11).

3.2.2 Georgia’s ageing population

According to the 2014 census, 14% of people in Georgia are aged 65 years or older. By 2050, this age group will rise to 25% of the population (12). WHO is working to refine measures of healthy ageing as part of its 10 Priorities for a Decade of Action on Healthy Ageing (13). The focus is now on older people’s functional ability within their environment, not their age or the conditions or diseases they have (14).

3.2.3 Persons with disability in Georgia

Rehabilitation intersects with the disability sector, since persons with disability are a key population group who may benefit from rehabilitation. Georgia ratified the UNCRPD in December 2013 and officially became a State Party on 13 March 2014.

Statistics on persons with disability living in Georgia are gathered by the National Statistics Office of Georgia (Geostat) as part of the general census of the population, and by the MoIDPLHSA Social Services Agency (SSA) on the basis of State allowances granted to persons with disability.

The 2014 census showed that there were 100 113 registered persons with disability in Georgia (2.69% of the population), while the SSA registered 118 651 persons with disability who were receiving social assistance as of 1 March 2015 (a difference of over 18 000). SSA figures increased to 125 104 in 2017 (15). Table 1 provides details of the Geostat figures from 2014 compared with those for SSA beneficiaries in 2017.

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Table 1. Estimates of persons with disability in Georgia

Information source Total Group I Group II Group III Children

2014 census 100 113 26 784 58 255 9902 5172

2017 SSA beneficiaries 125 104 26 568 75 268 5836 10 052

Disability categories:Group I: acute; Group II: considerable; Group III: moderate (16). Source: (15).

The system for the determination of disability status in Georgia is based predominantly on a medical model of disability; the current system focuses on a specific diagnosis, rather than on the overall state of health of the person and its impact on his/her daily functioning. UNICEF Georgia, in close cooperation with MoIDPLHSA, is implementing a pilot of the social model of disability assessment and status determination system in Adjara.

More information is provided in Section 8 below.

3.2.4 Persons with difficulties in functioning

In addition to collecting information on disability, the 2014 census also collected information on functioning.

The number of people with difficulty functioning is 1 301 675 (35% of the population). See Annex 7 and Section 8 below.

In 2018, Georgia carried out a Multiple Indicator Cluster Survey (MICS) that identifies 28% of adults and children (aged 2–49 years) as having difficulty functioning in at least one domain (17). See Section 8 below for details.

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4. Overview of Georgia’s

health and rehabilitation

system

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In 1999, the Ministry of Health merged with the Ministry of Social Affairs. Since then, areas such as labour, employment and issues relating to internally displaced persons (IDPs) from the occupied territories have been brought under a single ministry, MoIDPLHSA.

MoIDPLHSA is accountable for the health of the population, oversight of the health system, quality of health services and equity in access to health care throughout the country. It also provides oversight of social programmes supporting vulnerable populations.

Within the MoIDPLHSA structure, the Policy Department coordinates issues related to rehabilitation (see Fig. 3);

at the time of the assessment, Ms Nino Jinjolava was responsible for rehabilitation-related issues within the Social Protection Policy Unit and Dr Mzia Jokhidze occupied a similar function within the Health Policy Unit.

Fig. 3. Structure and organization of MoIDPLHSA in relation to rehabilitation

ESC&UAC: Emergency Situations Coordination and Urgent Assistance Centre; LEPL: legal entity of public law; MoIDPLHSA/MOLHSA: Ministry of Labour, Health and Social Affairs; NCDC; SFTV: Agency for State Care and Assistance for the (Statutory) Victims of Human Trafficking; SRAMA: State Regulation Agency for Medical Activities; SSA: Social Services Agency. Source: Author’s own.

Legal entities of public law (LEPLs) are independent bodies that carry out Government functions. The key LEPLs within MoIDPLHSA with links to rehabilitation within the health system are described in Table 2.

Table 2. Legal entities of public law within MoIDPLHSA related to health and rehabilitation

Name of LEPL Acronym Description of rehabilitation-related function Emergency Situations

Coordination and Urgent Assistance Centre

ESC&UAC Ensures/coordinates quality emergency medical and referral assistance in disaster and martial law situations. It is also responsible for managing emergency calls (#112) and ambulance services and for managing primary health care in villages.

National Centre for Disease

Control and Public Health NCDC The main institution responsible for health statistics. It provides national leadership in preventing and controlling communicable and noncommunicable diseases.

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OvERvIEw OF GEORGIA’S HEALTH ANd REHABILITATION SySTEM

Name of LEPL Acronym Description of rehabilitation-related function State Regulation Agency for

Medical Activities SRAMA Responsible for issuing licences for medical activities and permits for health-care facilities and pharmacies, and regulating medical professionals, pharmaceuticals and medical devices.

Social Service Agency SSA Responsible for purchasing publicly financed health services; it is the only actor in the health system for Government-funded cover under the UHCP and social assistance programmes.

Agency for State Care and Assistance for the (Statutory) Victims of Human Trafficking

SFTV Protection, assistance and rehabilitation of victims of human trafficking, violence against women/or domestic violence and victims of sexual abuse.

Creation of decent living conditions for people with disability, elderly people and orphaned children.

Georgia has experienced extensive health reform over the past 15 years.

The health-care system in Georgia is highly decentralized and was extensively privatized between 2007 and 2012. The main principles were to transition towards complete marketization of the health sector: private provision, private purchasing, liberal regulation and minimum supervision. The State retained control over a few medical facilities dealing with mental illness and infectious diseases, while all other hospitals and clinics were privatized (18). Approximately 84% of medical service providers are private (11).

The Government of Georgia introduced the UHCP in 2013. The UHCP extends publicly financed entitlement to health-care coverage to the entire population. The package covers a range of primary and secondary care services and limited essential drugs. More than 90% of the population are covered by the UHCP programme (11).

UHCP does not include rehabilitation services or assistive products.

Some standard indicators for health facilities and personnel are the number of health facilities, beds, physicians and nurses. Information for Georgia is provided in Table 3. Notably, there are almost twice as many doctors as nurses; the rural physician programme accounts for 55% of outpatient facilities.

Table 3. Overview of health facilities and human resources in Georgia

Description Number Number per 100 000

Number of inpatient facilities 273 N/A

Number of hospital beds 15 909 426.90

Number of physicians (including dentists) 30 998 831.90

Number of nurses 17 862 479.30

Number of outpatient facilities (includes rural figures) 2283 N/A

Rural physicians-entrepreneurs 1267 N/A

N/A: not applicable. Source: (11).

Table 2. contd.

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4.1 Other stakeholders in rehabilitation

In addition to MoIDPLHSA, the other ministries that play a role in rehabilitation are the Ministry of Defence (MoD) and Ministry of Education, Science, Culture and Sport (MoES). The MoD manages the National Hero of Georgia Mariam (Maro) Makashvili Military Rehabilitation Centre (see Section 9). The MoES houses the National Centre for Educational Quality Enhancement (NCEQE); see Section 7.

Besides private service providers, international organizations and nongovernmental organizations also contribute to the rehabilitation landscape. Some key intervention areas include workforce capacity-building (scholarships, in-country training and treatment protocols), provision of assistive products, facilitating dialogue and other actions.

The donor landscape for rehabilitation in Georgia is varied. Donors identified during the assessment are listed below.

– United States Agency for International Development (USAID): since 2005, USAID has invested nearly US$ 10 million in disability and rehabilitation. Current programmes: US$ 1.2 million to the United Nations Children’s Fund (UNICEF) (2015–2020) and US$ 4.5 million to Emory University (Atlanta, Georgia, United States of America) (2017–2021).

– Turkish Cooperation and Coordination Agency: provides 300 000 Georgian lari (GEL) (approx.

US$ 100 000) to renovate the existing Rehabilitation Centre for Persons Having Limited Ability Ltd.

(Tbilisi).²

– Between 2012 and 2015 over US$ 500 000 was donated by Foundation Johanniter, Government of Japan, International Committee of the Red Cross (ICRC) and the Georgian Foundation for Prosthetic Orthopaedic Rehabilitation (GEFPOR) to establish the Prosthetic Orthopaedic Rehabilitation Centre in Tbilisi.³

– Federal Ministry of Economic Cooperation and Development (BMZ), Germany: supports the nurse training module for home care (nine-year programme and funding amount unknown).

– Private investor: Ken Walker University Clinic for Medical Rehabilitation LLC (Tbilisi): US$ 6 million.

2 Source: interview with Centre Director, 20 February 2020.

3 Source: email from GEFPOR, 23 June 2020.

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5. Governance of

rehabilitation

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Key components Status Rehabilitation legislation

and policies There is no mention of rehabilitation in the current 2014–2020 health plan. Nearly all legislation and policies on rehabilitation are covered by a disability framework. Georgia ratified the UNCRPD in 2013.

The Human Rights Action Plan for 2018–2020 references habilitation and rehabilitation services for persons with disability.

Rehabilitation strategic plan Georgia has not yet developed a rehabilitation strategic plan.

Leadership and coordination Rehabilitation leadership focuses on guidance and financing for social programmes. There is an interagency group focused on early childhood development and three technical working groups (wheelchairs, adult rehabilitation, professional standards) linked to the Emory University project.

Rehabilitation accountability

and reporting Outside the disability context, there is no reporting on rehabilitation. There is no evidence of information collected about performance of rehabilitation, either within social programmes or in the health sector.

Regulatory mechanisms There are low levels of regulation that apply to rehabilitation and assistive technology. Licensing is only required for medical doctors. Pricing and guidance exists for some assistive products through social programmes.

Assistive technology (AT) policies, plans and procurement

Leadership for assistive technology exists, but all processes and management structure are housed within social protection. There are many gaps or deficiencies that require further attention. A formal AT assessment (with support from WHO) is planned for Georgia in 2020.

5.1 Rehabilitation governance and regulatory documents

Georgia’s current health plan, the 2014–2020 State Concept of Healthcare System of Georgia for Universal Health Care and Quality Control for the Protection of Patients’ Rights (19), identifies 10 priority areas for improvement.

There is no mention of rehabilitation in the document. MoIDPLHSA is currently employing a consultant, Lajos Kovacs, to support the development of the National Health Strategy 2021–2026.

The Government of Georgia issues an annual State Programme for Social Rehabilitation and Childcare (20). The goal of the programme is to improve the physical and social conditions of persons with disability including children and elderly, homeless and socially vulnerable people, and promote their social integration. The document outlines the approved subprogrammes, source of funding, beneficiaries, programme supervision, penalties and sanctions and programme implementation period. Information on funding is in Section 6, and services provided in 2019 through this programme are in Section 9.

Georgia ratified the UNCRPD in 2013; Article 26 references habilitation and rehabilitation. In 2017, Georgia drafted the Law on the Rights of Persons with Disabilities (not yet approved). Georgia’s Human Rights Action Plan for 2018–2020, approved by Decree #182 (17 April 2018), envisions an increase in accessibility to habilitation/

rehabilitation services for persons with disability and children, with the evaluation indicator of defining the capacity for developing rehabilitation needs and services for adults (Article 19.1.6).⁴

There are many policy documents pertaining to early childhood development:

– Decree #282 by the Parliament of Georgia, on Approving the National Concept on Early Childhood Intervention (ECI) Aimed at Early Childhood Development (dated 9 February 2017);

– Decree #01-188/o by the Minister of Labour, Health and Social Affairs on Approving the Minimum Standards on ECI (dated 18 August 2017);

– ECI subprogramme of the State Programme for Social Rehabilitation and Childcare;

4 Source: information provided in the TRIC, February 2020.

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17

GOvERNANcE OF REHABILITATION

– Decree #234 on the 2018–2020 National Action Plan for Implementing the National Concept on ECI (dated 15 May 2018);

– Decree #01-66/o by the Minister of MoIDPLHSA (20 August 2018) to Establish an Interagency Working Group to Coordinate the Implementation of the 2018–2020 National Action Plan for Implementing the National Concept on ECI.

5.2 Rehabilitation leadership, planning and coordination

Leadership for rehabilitation is historically grounded in the MoIDPLHSA social programmes for persons with disability. Except for guidance on the implementation of the State Programme for Social Rehabilitation and Childcare, there is very little planning or detail related to the rehabilitation workforce or services.

Although MoD, MoES and MoIDPLHSA each have a role in rehabilitation, there is little evidence of coordination across the three ministries. Conversely, coordination around early childhood development appears to be well established, with an interagency group on early childhood development as well as a coalition of early intervention service providers.

Based on the decision of the Project Support Board within MoIDPLHSA, three technical working groups were established in relation to the USAID-funded Physical Rehabilitation Project in Georgia.⁵ The 13-member Board is a cross-section of Government, professional associations, international organizations and universities. The three technical working groups focus on: wheelchair service provision, policy on adult rehabilitation, and professional standards, licensing and educational programmes within the project.

5.3 Rehabilitation accountability, reporting and transparency

Reporting on rehabilitation service delivery is at a low level, and data on the status and performance of rehabilitation are either not available or unknown.

5.4 Governance, procurement and regulation of assistive products

MoIDPLHSA has not yet created a priority assistive products list. The State Programme for Social Rehabilitation and Childcare provides some guidance on pricing and supplier criteria for assistive products (especially wheelchairs). The existing guidance and current pricing merit review; and the WHO-supported AT assessment is scheduled for mid-2020 are well timed.

5 This US$ 4.5 million project (2017–2021) is implemented by Emory University with Tbilisi State Medical University (TSMU), Coalition for Independent Living (CIL) and McLain Association for Children (MAC) Georgia.

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Specifically, in respect of wheelchairs, the system of wheelchair service provision in the country is supervised by MoIDPLHSA (responsible for development of the policy and the relevant subprogramme) and SFTV (responsible for implementation of subprogramme activities). In addition, a wheelchair service provision working group has been set up in Georgia as part of the physical rehabilitation project supported by Emory University. The working group implements the project activities in accordance with the action plan developed as part of the same project and is accountable to the Advisory Board of the project Physical Rehabilitation in Georgia.

Summary of rehabilitation governance situation

• MoIDPLHSA demonstrates a commitment to rehabilitation through support and actions articulated in the annual State Programme for Social Rehabilitation and Childcare.

• Leadership and coordination of rehabilitation is provided through the current MoIDPLHSA Policy Department (Social Protection Policy Unit and Health Policy Unit).

• Georgia has ratified the UNCRPD and drafted a national disability law.

• In Georgia, rehabilitation and disability are closely connected. Concerted efforts are needed to disentangle them in order to emphasize that rehabilitation is part of the health-care continuum and available to anyone who needs it.

• There is little or no evidence of systematic coordination between Government ministries on rehabilitation.

• There is no national plan for rehabilitation.

• There is no reporting on the status or performance of rehabilitation in health systems.

• There is limited evidence of accountability mechanisms between rehabilitation service providers and MoIDPLHSA. The only accountable medical facilities are those where services are provided by rehabilitation doctors (licensed/certified for independent medical practice). Service providers submit monthly reports to the Agency on the work performed.

• Only medical doctors are regulated (professional competencies) and require a licence to practise (Certificate for Independent Medical Practice). This requirement does not yet apply to any other members of the rehabilitation workforce.

• Early childhood development has many policy documents and coordination mechanisms.

• Assistive products are largely unregulated. The Government has few guiding frameworks for the procurement or provision of assistive products.

• No list of priority assistive products has yet been developed.

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6. Rehabilitation

financing

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Key components Status Mechanisms for rehabilitation

financing Rehabilitation financing within MoIDPLHSA is primarily for children and adults with disability.

All other rehabilitation is paid by individuals; almost exclusively as out-of-pocket expenditure (OOP).

Rehabilitation expenditure The three key budget lines for rehabilitation within MoIDPLHSA social rehabilitation and child care for rehabilitation include early childhood development, assistive products, and habilitation/

rehabilitation; the total budgeted amount is GEL 12 million (approx. US$ 4.3 million). See Table 4 below.

Rehabilitation expenditure as proportion of total health expenditure

The budget for social rehabilitation and child care represents less than 1% of the total MoIDPLHSA budget. Of that 1%, approx. 31% is budgeted for rehabilitation (as above).

Assistive product expenditure According to MoIDPLHSA 2020 budget, just over US$ 2 million is available for assistive products (see Table 4 below).

OOP costs of rehabilitation OOP payments for health care stand at over 50%. For adults without a disability determination, OOP costs for rehabilitation would be nearer 100%, as it is not covered under UHCP and generally not part of insurance.

6.1 Mechanisms for health (and rehabilitation) financing

In 2013, Georgia launched the UHCP, whereby the SSA reimburses providers according to agreed tariffs for specific conditions and procedures. By May 2017, the UHCP covered more than 95% of the population, based on the number of persons registered with a primary care provider (18). Rehabilitation and assistive products are not included in the UHCP package.

In addition to UHCP, the health budget also finances 23 vertical programmes for priority diseases and conditions.

The vertical programmes include mental health, diabetes management, child leukaemia services, dialysis and kidney transplantation, palliative care and a range of public health protection programmes, including tuberculosis control, vaccination programmes and the innovative hepatitis C programme (18).

Fig. 4. Health expenditure 2017

38%

55%

6% 1%

Public OOP VHI Intl donor

Source: CDC Statistical Yearbook 2018.

Public (38%): UHCP or vertical programmes

OOP (55%): out-of-pocket

VHI (6%): voluntary health insurance Intl donor (1%): International donors

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21

REHABILITATION FINANcING

Voluntary health insurance is also available in Georgia; it accounts for 5–7% of the health budget.⁶ OOP payments constitute the main source of revenue for health care (57%) (18). For a breakdown of health expenditure, see Fig. 4.

An additional source of financing is through municipal budgets. Each has the discretion to determine supplementary amounts for health-care or social programmes (including rehabilitation), and support for individuals is provided on a case-by-case basis. Information from municipalities was not collected during this assessment.

Table 4. MoIDPLHSA budget 2020

Budget line GEL US$ Percentage of

total

Total Government budget 13 000 000 000 4 659 563 265 100.00

1. MoIDPLHSA budget 4 363 000 000 1 563 821 117 33.56

1.1. Population health 1 079 000 000 386 743 751 8.30

1.1.1. Universal health care 757 136 000 271 421 517 5.80

1.1.1.2. Mental health 27 500 000 9 877 759 0.20

1.2. Social protection 3 126 000 000 1 120 996 145 24.04

1.2.1. Pensions 2 230 000 000 799 420 425 17.20

Subdivisions within social protection budget

1.2. Social protection 3 126 000 000 1 120 996 145 100.00

1.2.1. Pensions 2 230 000 000 799 420 425 71.30

1.2.2. Social rehabilitation and child care 37 400 000 13 411 790 11.90

Subdivisions within social rehabilitation and child care budget

1.2.2. Social rehabilitation and child care 37 400 000 13 411 790 100.00

1.2.2.1. Early childhood development 3 200 000 1 147 776 8.55

1.2.2.2. Day-care service provision 6 300 000 2 259 684 16.84

1.2.2.3. Assistive products 5 600 000 2 007 402 14.97

1.2.2.4. Habilitation and rehabilitation of children 3 440 000 1 233 859 9.19

1.2.2.5. Subprogramme to promote communication for deaf people 48 000 17 216 0.12 1.2.2.6. Subprogramme to provide home care for children with

severe and profound developmental delays 252 000 90 387 0.67

1.2.2.7. Subprogramme to provide home care for children with

severe and profound disability or health problems 255 500 91 642 0.68

MoIDPLHSA: Ministry of Internally Displaced Persons from the Occupied Territories of Georgia, Labour, Health and Social Affairs. Source: English version of the Georgian Basic Directions and Data (BDD) 2020–2023 Midterm Budget.

6 Information from finance meeting in Tbilisi, 11 February 2020.

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6.1.1 Autonomous Republic of Adjara

The Ministry of Health and Social Affairs of Adjara has its own budget.⁷ The total budget amount of the Ministry is GEL 21 000 000 (approx. US$ 7.6 million). Within this budget, there is a broad budget category of medical and social rehabilitation, GEL 2 767 280 (approx. US$ 1 million) with subprogrammes that resemble the MoIDPLHSA budget.

One unique characteristic of the Adjaran budget is an allocation for adult medical rehabilitation. This budget line, GEL 600 000 (approx. US$ 216 000) is listed within general medical services (code 06 02) and not within the medical and social rehabilitation code (06 05). The funding is for adults with disability.

6.1.2 Payment processes for rehabilitation treatments

Payment for rehabilitation is based on a preset number of treatments and/or vouchers, with maximum budget amounts clearly stated. In Georgia, rehabilitation is paid for children under the age of 3 years, children with disability (up to 18 years), adults with disability, elderly, war veterans and other vulnerable populations. The criteria for eligibility are clearly stated in multiple guidance documents.

For children (age 18 years and below), payments through SSA for one calendar year cover the following interventions:

– eight courses of treatment – GEL 330 (approx. US$ 120) maximum payment per course;

– one course is a maximum of 22 sessions; an individual can receive up to eight course per year;

– course duration is 10 days (generally administered over a one-month period).

In summary, a child is eligible for a total of 80 days of interventions that include up to 176 treatments, with a maximum contribution by the SSA of GEL 2640 (approx. US$ 950) per calendar year.

In Adjara, rehabilitation payments for adults with disability in one calendar year include:

– two courses of treatment – GEL 600 (approx. US$ 215) maximum payment per course;

– there must be at least 15 sessions (procedures or treatments) – maximum one procedure per day.

In summary, an adult with disability in Adjara is eligible for 30 days of interventions for a total ceiling of 30 procedures/treatments with a maximum contribution of GEL 1200 (approx. US$ 430) per calendar year.

For assistive products, SSA mails a voucher for the amount it will reimburse. The individual takes this voucher to an approved service provider to receive the product.

6.2 Rehabilitation expenditure

The projected 2020 rehabilitation budget within social protection is over US$ 6 million (see Table 4).

7 Source: 2020 budget in Georgian, shared during the meeting on 24 February 2020.

Situation assessment of rehabilitation in Georgia

Situation assessment of rehabilitation in Georgia

February 2020

Situation assessment of rehabilitation in Georgia

February 2020

Keywords

Contents

Acknowledgements

Contributors

Authors

Editors

Peer contributors (individuals and organizations)

Peer reviewers

Abbreviations

Executive summary

Key findings

Governance

Financing

Human resources

Information

Rehabilitation services

Key recommendations

Governance

Financing

Human resources

Information

Rehabilitation service

1. Background

and methodology

1.1 International, regional and national developments in rehabilitation

1.2 Methodology

1.2.1 Stage 1 (completion and consolidation of a standard questionnaire)

1.2.2 Stage 2 (in-country data collection and preliminary read-out)

1.2.3 Limitations

2. Introduction

to rehabilitation

Fig. 1. Aims of rehabilitation interventions

3. Health trends and

rehabilitation needs

in Georgia

3.1 Georgia country context

3.2 Health context, trends and rehabilitation needs in Georgia

3.2.1 The rise of noncommunicable diseases in Georgia

Fig. 2. Estimated mortality in Georgia

3.2.2 Georgia’s ageing population

3.2.3 Persons with disability in Georgia

Table 1. Estimates of persons with disability in Georgia

3.2.4 Persons with difficulties in functioning

4. Overview of Georgia’s

health and rehabilitation

system

Fig. 3. Structure and organization of MoIDPLHSA in relation to rehabilitation

Table 2. Legal entities of public law within MoIDPLHSA related to health and rehabilitation

Table 3. Overview of health facilities and human resources in Georgia

Table 2. contd.

4.1 Other stakeholders in rehabilitation

5. Governance of

rehabilitation

5.1 Rehabilitation governance and regulatory documents

5.2 Rehabilitation leadership, planning and coordination

5.3 Rehabilitation accountability, reporting and transparency

5.4 Governance, procurement and regulation of assistive products

Summary of rehabilitation governance situation

6. Rehabilitation

financing

6.1 Mechanisms for health (and rehabilitation) financing

Fig. 4. Health expenditure 2017

Table 4. MoIDPLHSA budget 2020

6.1.1 Autonomous Republic of Adjara

6.1.2 Payment processes for rehabilitation treatments

6.2 Rehabilitation expenditure